Management of Depression in the Primary Care Setting

1. Management of Depression in the Primary Care Setting Alan L. Podawiltz, D.O., M.S. Chair, Psychiatry and Behavioral Health www.jpsbehavioralhealth.org

2. Learning Objectives After your participation in this session you should be able to: • DESCRIBE the epidemiology of depressive disorders. • DESCRIBE symptoms of depressive disorders. • DIFFERENTIATE/DIAGNOSE the characteristics of depressive disorders • DESCRIBE drugs and medical illnesses that may induce depression • DESCRIBE physiologic abnormalities caused by psychotropic medications: • DESCRIBE common adverse effects of psychotropic agents • DESCRIBE strategies to assist the compliance of patients with recommended treatment. • Impact of illness on activities of daily living, • Early development • Access to diagnosis and treatment • Cultural influence on illness

3. Biopsychosocial Affect Environment Cognition Behavior

4. Biopsychosocial Affect Environment Behavior Cognition

5. Major Depressive Disorder Lifetime prevalence in women: 21.3%1 Lifetime prevalence in men: 12.7%1 Most prevalent in women between onset of menstruation and menopause2 Kessler RC et al. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56(7):617-626. Cohen LS et al. H. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.

6. Risk of Depression by Age & Sex Kessler R, et al. J Affect Disord. 1993; 29:85-96.

7. Comorbidity and Depression 72.1% of those with lifetime MDD and 64% of those with 12-month MDD have at least one additional mood disorder Primarily anxiety disorder, substance abuse disorder, or impulse control disorder Kessler RC et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095-3105.

8. Major Depressive Disorder (MDD) One or more major depressive episodes Absence of any history of manic, mixed, or hypomanic episodes Relapsing and remitting Episodes may last months or, more rarely, years Half of all episodes fully remit within 6 to 12 months with or without treatment Up to 20% of those who experience an initial episode may develop chronic depression After an initial episode, the patient is predisposed to additional episodes which become more severe and last longer Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004

9. Depression Very common Associated with significant dysfunction Under diagnosed Often chronic or recurrent Commonly present with other GMC Highly treatable Multiple safe and effective treatments are available

10. Major Depressive Disorder Relapsing and remitting course • May eventually become chronic Minimum duration ≥ two weeks Clear distinction between episodes and inter-episodic function • Often well or at least much better between episodes

11. Two Questions Over the last two weeks: • Have you felt down, depressed, or hopeless? (Mood) • Have you felt little interest or pleasure in doing things? (Interest)

12. Two-Steps for Depression Screening Over the past 2 weeks have you felt down, depressed, or hopeless? Over the past 2 weeks have you felt little interest or pleasure in doing things? Probe deeper, be proactive, engage in conversation about mood and changes in behavior 24% - 40% of patients with positive screen receive MDD diagnosis Others may have dysthmia, subsyndromal depressive disorders, anxiety, PTSD, substance abuse, panic disorder, or grief disorder Step One: Two-Question Depression Screen Step Two: If Screen is Positive… A “yes” to either question is a positive initial screen for depression… US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764

13. Visual Screening Tool Ask the patient to point to theface that best represents how she/hehas felt in the past 2 weeks. Depression in Women Series, PACE, 2007

14. Recommended Instruments • QIDS: Quick Inventory of Depressive Symptomatology (http://www.ids-qids.org) • PHQ-9: Patient Health Questionnaire-9(www.phqscreeners.com) Both instruments are… Validated Quickly and easily administered and scored Available to download Available in English and Spanish Helpful for initial screening AND evaluation of treatment response

15. SIGECAPS S I G E C A P S - Changes in sleep pattern - Changes in interests or activity - Feelings of guilt or increased worry - Changes in energy - Changes in concentration - Changes in appetite - Psychomotor disturbances - Suicidal ideation

16. Major Depressive Disorder Core symptoms: SIGECAPS • Depressed mood (sad, down, blue) AND/OR • Reduced interest or pleasure (I) Somatic symptoms: • Change in appetite (A) • Change in sleep pattern (S) • Reduced energy level (E) • Psychomotor agitation/retardation (P) Cognitive symptoms: • Poor concentration/easy distraction (C) • Inappropriate guilt/self reproach (G) • Thoughts of death, dying, suicide (S) 5 out of 9 for at least two weeks

17. The Suicide Question If an adult, child, or adolescent says, “I want to kill myself, or I'm going to commit suicide” Always take this statement seriously and immediately seek assistance from a qualified mental health professional People often feel uncomfortable talking about death. However, asking the adult, child, or adolescent whether he or she is depressed or thinking about suicide can be helpful. Rather than putting thoughts in the person's head, such a question will provide assurance that somebody cares and will give the person the chance to talk about problems

18. U.S. Suicides 11th leading cause of death 8th leading cause of death for males 19th leading cause of death for females 1.3% deaths suicide • 29% heart diseases • 23% malignant neoplasms • 6.8% cerebrovascular disease

19. Suicide Risk Screening Depression in Women Series, PACE, 2007

20. Suicide Risk Assessment Depression in Women Series, PACE, 2007

21. Explore the Differentials Depressive Disorders • Psychiatric • Major Psychoses • Adjustment D/O w/ depression • Bereavement (up to 2 months) • General Medical • Hypothyroidism = classic rule-out • Post-CVA, Post-MI • Ca of head of pancreas • Substance-Related • Alcohol abuse, cocaine/amphetamine withdrawal • Rx meds: steroids, b-blockers, a-methyldopa

22. Comorbid Medical Conditions Asthma1 Pain2 Arthritis1 Cardiovascular disease1 Stroke3 Diabetes1 Obesity1 Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14. Gureje O et al. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1-2):195-200. Gillen R et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82(12):1645-1649.

23. Substances Related to Sexual Dysfunction • Antidepressants • Lithium • Sympathomimetics •  and  - adrenergic antagonists • Anticholinergics • Antihistamines • Anti-anxiety agents • Alcohol • Opioids • Hallucinogens • Cannabis • Barbiturates • Sedative hypnotics

24. Sexual Dysfunction and Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) • Increases serotonin levels in both sexes • Decreases sex drive • Impairs orgasm • 5HT2A Agonist Tricyclic Antidepressants (TCAs) • Drying of mucosal membranes • Reduction of lubrication • Stimulation of 5HT2A receptors • Inhibits erection and ejaculation

25. CVD and Depression Patients with cardiovascular disease (CVD) more likely to experience depression1 Patients with depression 1.6 times more likely to develop coronary artery disease (CAD); even more likely with MDD1 Also 4 times more likely to experience a myocardial infarction (MI)1 Post-MI patients with depression less likely to follow lifestyle changes2 Pratt LA et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation. 1996;94(12):3123-3129. Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000;160(12):1818-1823.

26. Depression and Diabetes Depression twice as prevalent in those with diabetes More prevalent in women with diabetes than in men with diabetes Anderson RJ et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-1078.

27. Depression and Obesity 65% of the US population is overweight or obese More obese women than men (54% vs. 46%)1 BMI ≥30 in women associated with nearly 50% increase in lifetime prevalence of depressive disorders2 Ogden CL et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555. Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.

28. Practice Recommendation Screen patients with any chronic health condition for depression, especially patients with diabetes, cardiovascular disease, or chronic pain. US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764 AAFP Approved source: Institute for Clinical Systems Improvement Website: http://www.icsi.org/depression_5/depression__major__in_adults_in_primary_care_3.html Strength of Evidence: Grade A (randomized, controlled trials)

29. Study of Women’s Health Acrossthe Nation (SWAN) Depression risk highest in: • Early or late perimenopause • Using hormone therapy (OR=1.30 – 1.71) • Late vs. early perimenopause • BrombergerJT et al. Depressive symptoms during the menopausal transition: The Study of Women's Health Across the Nation (SWAN). J Affect Disord. 2007

30. Harvard Study of Moods and Cycles Nearly twofold increased risk of depression in women entering perimenopause (OR=1.8) Hot flushes associated with greater risk of MDD (OR=2.2) Cohen LS et al. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.

31. Major Neurotransmitters Serotonin Norepinephrine Anxiety Irritability Energy Interest Impulsivity Mood, Emotion,Cognitive function Sex Appetite Aggression Motivation Drive Dopamine

32. Role of Serotonin in the CNS Serotonin influences a wide variety of brain functions • Mood • Sleep • Cognition • Sensory perception • Temperature regulation • Nociception (e.g., migraine headache) • Appetite • Sexual behavior Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998. Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed. 1996. Nemeroff C. Scientific American. June 1998;42-49.

33. Role of Dopamine in the CNS Dopamine modulates various brain functions • Mood • Cognition • Motor function • Drive • Aggression • Motivation Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998. Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed. 1996.

34. Role of Norepinephrine in the CNS Norepinephrine plays an important role in the brain affecting • Mood • Learning and memory • Regulation of sleep-wake cycle • Regulation of hypothalamic-pituitary axis • Regulation of sympathetic nervous system Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998. Nemeroff C. Scientific American. June 1998;42-49. Frazer A. J Clin Psychiatry. 2000;61(suppl 10)25-30.

35. Undertreatment Evidence Lewis E, et al. Patients' early discontinuation of antidepressant prescriptions. Psychiatr Serv. 2004;55(5):494. Lin EH et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83. Simon GE et al. Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Arch Gen Psychiatry. 2001;58(4):395-401.

36. Patient Adherence Patients are often reluctant to engage in therapy.1 More than half of patients treated for depression in primary care practices stopped drug treatment within 3 weeks. 2 Why?? Weren’t told how long it would take to feel better Weren’t warned about side effects Weren’t told I needed to continue once I felt better2 • HirschfeldRM et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4):333-340. • Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.

37. Antidepressant Warnings All patients being treated with antidepressants for any indication should be monitored closely for: • Clinical worsening • Suicidality • Unusual changes in behavior Monitor these patients especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Antidepressant Use in Children, Adolescents, and Adults http://www.fda.gov/cder/drug/antidepressants/default.htm

38. Practice Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost. Choose any class of antidepressant as a first-line treatment for MDD. Ask patients from different ethnicgroups about their treatment preference for MDD. AAFP Approved source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152

39. Maintenance Patients with one lifetime episode of MDD who achieve remission on antidepressants should continue to take them for another 6 to 12 months. Patients with two or more episodes should be maintained an additional 15 months to 3 years. Patients with chronic MDD or MDD with concurrent dysthymia should be continued on antidepressants an additional 15 to 28 months after the acute phase treatment. Kaiser Permanente Care Management Institute. Depression clinical guidelines. http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999

40. Practice Recommendation Follow up with patients on antidepressants for MDD: • At least once within the first month • At least once more 4 to 8 weeks after the first contact Assess for adherence, side effects, suicidal ideation, and response. AAFP Approved Source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152 Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

41. Practice Recommendation Advise patients that: Most people need to be on antidepressant medication for at least 6 months. It may take 2 to 6 weeks to see any improvement. It is very important to take the medication as prescribed, even after they start feeling better. They should not stop taking the medication without calling the provider first. Changing the dose or dose schedule can help manage side effects. AAFP Approved Source: Institute for Clinical Systems Improvement. http://www.icsi.org/depression_5/depression_major_in_adults_in_primary_care_3.html

42. Steps for Choosing an Effective Antidepressant Recognize that some antidepressants may be more effective in certain populations even though most are generally of equal effectiveness. Ask about personal or family history of treatment with antidepressants, particularly about side effects. Consider the burden of side effects, particularly weight gain and sexual side effects in midlife women. Consider drug-drug interactions with other medications the patient is taking or may take. Consider the potential lethality of the antidepressant in the case of an overdose. Use antidepressant side effects for efficacy. Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004.

43. Treatment Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost. AAFP Approved Source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152 Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

44. Follow-Up Considerations In The First Three Months

45. Other Options Include . . . Combine antidepressants and psychotherapy Increase dose of initial antidepressant Combine treatment with SSRI and low-dose desipramine (monitoring for TCA toxicity) Switch to different antidepressant of same or different class Augment with low-dose (300–600 mg/day) lithium in consultation with psychiatrist Switch from psychotherapy to antidepressants, or antidepressants to psychotherapy Kaiser Permanente Care Management Institute. Depression clinical practice guidelines. http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999. Accessed May 2, 2007.

46. Treatment Goal The goal of treatment with antidepressant medication in the acute phase is the remission of major depressive disorder symptoms APA Practice Guidelines for the Treatment of Psychiatric Disorders.

47. Follow Up after Initial Treatment Follow up with patients on antidepressants for MDD: • Individualize visit frequency for each patient • Patient’s starting or switching to a new RX should be seen every two weeks until stable • Patient’s at increased risk for suicidality or self-injury seen more frequently • Contact all patients in early phase of treatment to assess for suicidality or self-injury • Assess response with validated tool Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual- http://www.dshs.state.tx.us/mhprograms/tmapover.shtm

48. Maintenance 50% of MDD patients will experience recurrence after initial episode without long-term treatment 3< episodes – maintain AD therapy as preventative Duration varies depending on risk factors from 1 year to lifetime Consider maintenance after 2 episodes for patients with high risk factors, PTSD, co-morbid anxiety, chronic depression or serious personality disorder Increased stressors may warrant longer maintenance Weilburg JB, O'Leary KM, Meigs JB, Hennen J, Stafford RS. Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatr Serv. 2003;54(9):1233-1239. Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual- http://www.dshs.state.tx.us/mhprograms/tmapover.shtm

49. Continuation Continuation bridges remission to recovery Patients who remit should continue RX at least 6-9 months after remission at same dosage at which response was achieved Visits every 3 months Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual- http://www.dshs.state.tx.us/mhprograms/tmapover.shtml

50. Increasing the Likelihood of Remission Measurement-based care Optimize dose/extend trial Selection of antidepressant Role of adherence Pharmacologic adjuncts Role of psychotherapy Rush AJ, et al. J Clin Psychiatry. 1997;58(suppl 13):14-22. Thase ME, et al. Am J Psychiatry. 1999;60(suppl 22):3-6. Trivedi M et al. Am J Psychiatry. 2006;163(1):28-40.